Prefer to email or post?

Would you prefer to email us or send us a letter by post? If so, click the button below to download a Microsoft Word version of the referral form which can be attached to an email or sent to us by post.

Referral Form

Client 1






Client 2






Child(ren)'s Details

First Name



Surname Name



Gender

MaleFemale
MaleFemale
MaleFemale

Date of Birth

Child issuesProperty & FinanceAll Issues

Privacy note - Please note that by completing this referral form you are giving consent to Mediation Associates to hold limited personal information in order to enable you to get access to the mediation information and assessment process introduced by the Children and Families Act 2014, s 10). This information will be held securely and will only be used for the purpose of providing information or mediation and where appropriate securing legal aid. You can request your data be removed from our systems by contacting us in writing.